Ndika Fomukong, P.A.C

Primary specialty

Primary Care Nurse PractitionerTaxonomy code 363LP2300X

License

NP 17180 Issued in CA

Practice address

6470 Van Nuys Blvd Ste D
Van Nuys, CA 91401-1499

Phone

(323) 733-7242

Fax

(310) 975-1292

NPI assigned

May 23, 2006

Last updated

Apr 10, 2026By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in CA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Nurse Practitioner, Physician Assistant

State licenses

Networks

• BSC 65 PLUS INDIVIDUAL MAPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1148342400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1775779200000",
    "number": "1497700066",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6470 VAN NUYS BLVD STE D",
            "city": "VAN NUYS",
            "state": "CA",
            "postal_code": "914011499",
            "telephone_number": "323-733-7242",
            "fax_number": "310-975-1292"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6470 VAN NUYS BLVD STE D",
            "city": "VAN NUYS",
            "state": "CA",
            "postal_code": "914011499",
            "telephone_number": "323-733-7242",
            "fax_number": "310-975-1292"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "FOMUKONG",
        "first_name": "NDIKA",
        "credential": "P.A.C",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-05-23",
        "last_updated": "2026-04-10",
        "certification_date": "2026-04-10",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "CA",
            "license": "PA17839",
            "primary": false
        },
        {
            "code": "363LP2300X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Primary Care",
            "state": "CA",
            "license": "NP 17180",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Primary Care Nurse Practitioner in Van Nuys, CA
• Providers in Van Nuys, CA by specialty
• Primary Care Nurse Practitioner in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 10, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.